Provider Demographics
NPI:1578950457
Name:SMITH, NICOLE ASHLEY (COTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ASHLEY
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150B BROADTURN RD
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9600
Mailing Address - Country:US
Mailing Address - Phone:978-424-6658
Mailing Address - Fax:
Practice Address - Street 1:895 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-9673
Practice Address - Country:US
Practice Address - Phone:207-439-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-19
Last Update Date:2015-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA3005224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant